Exclusive Article for EMRIndustry.com
By Donald M. Voltz, MD, Aultman Hospital, Department of Anesthesiology, Medical Director of the Main Operating Room, Assistant Professor of Anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.
Board-certified in anesthesiology and clinical informatics, Dr. Voltz is a researcher, medical educator, and entrepreneur. With more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the translation of ideas into viable medical systems and devices.
Thanh Tran, CEO of Zoeticx, Inc. also contributed.
While hospitals continue to hesitate to implement connectivity solutions like middleware to address their EHRs’ lack of interoperability, there are some specific systems that are most vulnerable to errors. System weak spots, including use of active instead of passive data, lack of collaborative workflow, single screen mobile access for disparate medical teams, alert escalation, and other long neglected areas should be focused on to help reduce needless deaths.
According to the Institute of Medicine (IOM), 44,000 -98,000 people die annually from medical errors. If you use the lower estimate, it places medical errors as the 8th leading cause of death in America. Estimations on the cost of these errors are between $17-$29 billion dollars yearly. If you look at these statistics, many errors arise from the way health systems are organized.
Some of the problems arise from issues pertaining to coordination of care, use of high concentration medications that require dilution and modifications in administration at the point of care, poor communication due to illegible orders or errors, omissions, or documentation of intended medication, route and dose.
These can be broken down into four major categories.
1. Diagnostic – delay, wrong diagnosis,
2. Treatment – error to perform, dose, delay, inappropriate
3. Prevention – missed, inadequate monitoring, categorization
4. Other – failure to communicate, equipment, system failures
In healthcare, there are numerous areas that are particularly vulnerable to error. Acute care settings are at a higher risk due to the complexity of care, time critical interventions, systems, staffing, communications not optimized, etc.
One of the major claims of EHR’s is to impact errors and allow for more efficient and cost effective care through improved quality, reduction of duplication, and reduction of documentation errors. However, most arise from system issues in the systems and not from reckless individual care.
Why Active Data is Crucial to Improved Patient Care
Healthcare is a dynamic and complex system requiring a great deal of data interpretation, intervention and communication. When we look just at the data side of the coin, passive data alone is worthless. It needs to become active and synthesized into a picture of health or disease for a given individual. This process has been called turning data into information. Physicians and other care providers are dependent on it for collaboration and treatment.
EHR’s have been built and designed around the collection of data, but do not yet bring context to the data. In addition, due to the complexities and differences between EHR and other health data systems, medical professionals are constantly presented with different user interfaces that must be consciously thought about to appropriately gather data as well as capture their decisions and treatment plans. Healthcare 2.0 vendors like Zoeticx and others recognize the importance of active data.
Medical professionals across the healthcare continuum depend on these EHR systems to communicate information (orders, need for tests or other interventions) to other providers. This leads to the potential for more errors in the following ways.
- Users of these systems are constantly searching for the data they need to make and modify treatment decisions. There is not a uniform display or presentation of the data in a way that reduces errors. Providers are required to search through multiple screens of information, jump to different parts of EMR’s or even access various EHR’s or other health information data sources in order to construct a complete data package for a single patient.
- We are forced to manually take notes on various pieces of information in order to draw conclusions. This is time consuming and error prone. This cognitive load, especially in a high stress situation, increases the risk of error. It also increases the possibility of accessing information on the wrong patient, perform the wrong action, or place the wrong order.
- Because information can be entered into various areas of the EHR, the possibility of duplication or missing information arises. For example, a diabetic patient who has glucose value checked and entered into an EHR. This piece of information which can be a critical value if too low, requiring immediate intervention to prevent a negative outcome, can be entered in a nurses’ note, a lab section of the EHR, a point of care documentation or other area.
- Another area in the EHR system where errors can arise pertains to alert fatigue. This stems from designs used to build user interfaces, often added onto the systems with the goal of reducing errors, but can lead to added burdens that increase frequency or severity of error outcomes. In addition, interaction with the EHR can lead to alerts or warnings when a user interacts with the data or places orders on a patient. These alerts and warnings are generally developed in EHR silos and there is poor understanding and testing of these alerting systems.
When I look at the EHR, I am often presented with a list of documentation located in different folders that can be many computer screens long. If I am searching for the glucose reading, there are many issues that can lead to errors. I may miss the critical value because I may have missed the information contained inside a nurses’ note. If the lab was not performed by the nurse, I might never know unless I specifically remember asking the nurse to do the measurement.
How Hospitals Can Help Prevent EHR Related Errors
The initial goal of hospitals was to implement EHR’s to address many of the healthcare system issues that lead to errors. The goal and promise of these EHR’s was to “fix” these system errors. Given the widespread adoption of EHRs in hospitals, clinics, offices and health systems, stimulated by the HITECH Act, it is unlikely that EHRs will go away, and unnecessary; they simply need to be modified.
Instead of expecting EHR vendors to address all of these design and implementation issues, we need to look for another solution. One of the greatest areas of interest and focus that also impacts the safety of care delivered is interoperability of these various systems.
Hospitals need to look for ways to address many of these issues and develop technology that reduces physician and other care provider workflow and workarounds for current EHR systems as well as address specific needs for different areas, specialties, procedures, etc. In looking at the various issues, the number of EHR systems and the complexity of healthcare, we need a platform that can interface these systems and provide consistent, reliable displays of information, enhance communication of patient care between various providers and across the continuum of care.
A platform to address these issues must include interoperability between systems. It must also allow sharing of patient information between various physicians and providers caring for a patient to provide smart alerting to address issues with alert fatigue. Accountability and answerability of information generated, and care provided to a patient, including escalation of alerts when issues are not being addressed in a timely and appropriate manner.
It needs to enable documentation and automated capture of critical information from a clinical, quality and administrative standpoint. Providing automatic documentation that a provider has viewed and addressed is a critical value, ensuring appropriate documentation has been performed for a given quality metric or to support a diagnosis code.
Also allow for appropriate billing and reimbursement at the time of care delivery and not many weeks or months later when a claim is denied or quality incentive not reimbursed.
Provide for custom development of workflows, interfaces or the addition of new health databases. Allow for telemedicine and the remote access to patient information at a single or across multiple health systems that have various EHR implementations.
This list is a complex and challenging one for Healthcare 2.0 providers, but has been tackled by Zoeticx. The company not only uses middleware as the technology that drives its connectivity platform, but has developed a single user interface display of patient medical information. It is aligned with physician provider workflows and also seamlessly integrates patient health data from different EHR systems for a single patient.
Zoeticx enables access to the information in a standardized way, irrespective of where the data is actually stored. In addition, when information is not present in the display, I can more quickly recognize this because the screen displaying the information is consistent, something not currently present in the health systems I interact with.
As a physician, I should not have to deal with the technology and engineering issues of the EHR. I want to access information pertinent to the care I am providing, irrespective of which system is storing the information. Currently, I need to switch contexts frequently, either within a single health data system or between them in order to gather all of the information I need on a patient.
